Healthcare Financial Services IG Edition 1
0.3.0 - ci-build Saudi Arabia flag

Healthcare Financial Services IG Edition 1 - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Claim: Claim Pharmacy Request #1

Generated Narrative: Claim 483078

Claim Batch Identifier: http://saudicentralpharmacy.sa.com/identifiers/batch/123456787879zxc2345678ujh

Claim Batch Number: 1

Claim Batch Period: 2023-12-06 --> 2023-12-06

Authorization Offline Date: 2023-12-05 11:05:48+0300

Episode: http://saudicentralpharmacy.sa.com/identifiers/episode/EpisodeID-209-0120

identifier: http://saudicentralpharmacy.sa.com/identifiers/claim/req_1902483080

status: Active

type: Pharmacy

subType: OutPatient

use: Claim

patient: Ahmad Khaled Abbas(official) Male, DoB: 1984-12-25 ( Passport Number: G12345678)

created: 2023-12-05 09:20:15+0300

insurer: Organization Saudi National Insurance

provider: Organization Saudi Pharmacy

priority: Normal

Payees

-Type
*Provider

SupportingInfos

-SequenceCategoryValue[x]
*1Days Supply30 d (Details: UCUM coded = 'd')

Diagnoses

-SequenceDiagnosis[x]Type
*1Viral infection, unspecifiedPrincipal Diagnosis

Insurances

-SequenceFocalCoveragePreAuthRef
*1trueCoverage: identifier = http://sni.com.sa/identifiers/memberid#0000000001; status = active; type = extended healthcare; dependent = 01; relationship = Self; network = Golden CPseudo-payer-Portal-Auth-02

item

Patient Share: SAR0.00 (SAR)

Package Code: false

Tax: SAR9.00 (SAR)

Patient Invoice: http://saudicentralpharmacy.sa.com/identifiers/patientInvoice/Invc-20220120-90408

Prescribed Medication: 06285096001627

Pharmacist Selection Reason: patient request

Maternity: false

sequence: 1

diagnosisSequence: 1

informationSequence: 1

productOrService: RELENZA 5MG POWDER FOR INHALATION

serviced: 2023-12-04

quantity: 1

UnitPrices

-ValueCurrency
*60Saudi riyal

Nets

-ValueCurrency
*69Saudi riyal

Totals

-ValueCurrency
*69Saudi riyal